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UNITED STATES OF AMERICA. 




ESSENTIALS 



OF 



Physical Diagnosis 



FOR 



MEDICAL STUDENTS. 



BY 

W. Henry Price, B.A., M.D., 

Quiz-Master in Physical Diagnosis in the Demonstrators' Quiz Association ; Attending 

Physician to the Children's Dispensary of the University Hospital ; 

and Physician to the Out-door Department of 

St. Clement's Hospital. 



PHILADELPHIA. 
1893. 



jfft'9' 



T^ 



Copyrighted, 1893, by W. Henry Price, M.D. 







PREFACE. 



The excuse for offering the present volume is not 
because of any deficiency in treatises on Physical Diag- 
nosis, but because most of these works are too volumi- 
nous and contain more details and exceptions than the 
average student can grasp during the first part of his 
medical career. It is well to start with a foundation of 
principal facts, and after these are thoroughly mastered 
it becomes much easier to appreciate and understand 
the exceptions to the general rule which are met with in 
atypical cases. 

After having quizzed upon this subject of Physical 
Diagnosis for several years, in connection with Univer- 
sity teaching, this fact has become emphasized to me, 
and at the request of many students the book has been 
compiled. 

Its object is to furnish to medical students of the 
First and Second year classes/ just that material which 
is required of them by the respective examiners. 

Both sets of lectures have been incorporated, and as 
they are identical, in the main, it only became necessary 
to indicate (by the asterisk) those points in which the 
two courses did not agree. 

(3) 



The subject-matter has been arranged in the form 
of questions and answers, thus giving all the necessary 
points and, at the same time, showing how the ques- 
tions are usually asked at the final examinations. My 
sincere thanks are due to both Dr. John H. Musser and 
Dr. Judson Daland for so willingly reading over the 
proof. If the book prove of any value to beginners 
toward the clearer understanding of fundamental truths 
in the art of discriminating disease, it will have accom- 
plished the purpose of 

THE AUTHOR. 
208 south 37th street. 
February 1893. 



CONTENTS. 



Physical Diagnosis, definition, methods ... 7 

Inspection and Decubitus 7 

Mensuration and Palpation . 8 

Percussion . . . 10 

Auscultation 12 

Vocal Resonance — Bronchophony 13 

Pectoriloquy — ^Egophony 14 

Respiration. — Rate. — Types of Breathing 14 

Components of Respiratory Murmur . . . ..... 14 

Changes in Vesicular Murmur 14 

Cheyne-Stokes Breathing 15 

Kinds of Breathing met with in Disease 15 

Puerile Breathing 16 

Emphysematous and Asthmatic Breathing . 17 

Regions of the Chest '. . 18 

Adventitious Sounds. — Rales . . . . 20 

Metallic Tinkling 21 

Hippocratic Succusion Splash 22 

Description of Normal, Phthisical, Rachitic and Em- 
physematous Chests 22 

Pulmonary Diseases : 

Acute Bronchitis 23 

Capillary Bronchitis 24 

Croupous Pneumonia 24 

Catarrhal Pneumonia 25 

Tuberculosis, Phthisis, Forms of . 26 

Acute Miliary Tuberculosis 28 

Pulmonary Emphysema, Varieties . . . • 28 

Asthma • • • 29 

Pleural Affections : 

Acute Pleurisy .- 31 

Pyothorax — Plastic Pleurisy . 32 

(5) 



Pneumothorax 32 

Hydro- and Pyo-Pneumothorax 34 

Cardiac Diagnosis: 

Circulation of the Blood ; 35 

Size and Weight of the Heart 35 

Study of the Apex-beat 36 

Triangles of Cardiac Dulness i>7 

Valve Areas 38 

. Heart Sounds and their Causes 38 

Endocarditis 39 

Diagnosis of Organic Heart Murmurs 40 

Diseases of the Heart Muscle ... ..*..... 42 

Hypertrophy, Dilatation, Fatty Infiltration 43 

Fatty Degeneration 44 

Angina Pectoris 44 

Pericarditis 44-45 

Aneurism 46 

Exophthalmic Goitre 47 

The Pulse 48 

Sphygmograph — Spyhgmogram 50 

Abdominal Diagnosis : 

Regions of Abdomen 51 

Spleen, Liver, Stomach 52 

Lavage, Gavage— Tests for Hydrochloric Acid .... 52 

Test for Pepsin 53 

Tests for Gastric and Intestinal Absorption $3 

Meteorism — Tympanites 54 

Scaphoid Abdomen — Ascites 54 

Suppression and Retention of Urine 54 

Palpation and Percussion of Kidneys ... 55 

Temperature 55 

Blood 56-65 

Miscellaneous . ^-73 

Table of Differential Diagnosis between Organic and 

Functional Heart Murmurs 74 

Table of Rales 75 

Table of Endocardial Murmurs 76 

Staining Tubercule Bacilli ... 77-7% 

Urine 79-81 



ESSENTIALS OE PHYSICAL DIAGNOSIS. 



What is Physical Diagnosis ? 

The discrimination of disease by the aid of the spe- 
cial senses. 

What methods are employed in Physical Diagnosis? 

Inspection, Mensuration, Palpation, Percussion and 
Auscultation. 

Which is the most valuable of these in Chest diseases ? 
Auscultationr 

Which in Abdominal Diagnosis ? 
Palpation and Percussion. 

What can be learned by Inspection in Lung diseases ? 

Shape and expansion of the Chest ; any prominence, 
depression, or inequality, and Decubitus. 

How is Inspection divided? 

Into General and Local inspection. 

What do you mean by Decubitus ? 

Decubitus means position in bed, and is characteris- 
tic in certain diseases, such as Peritonitis, Pleurisy 
and Pneumonia. 

(?) 



8 

What is Mensuration ? 

Measuring — (not often employed). 

What instrument is used for Mensuration ? 

Either the Cyrtometer or an ordinary tape-measure. 

Describe the Cyrtometer ? 

It consists of a saddle (fitting over the spine) and 
two arms of flexible metal graduated in inches. 

Do both chests measure the same normally ? 

In right-handed people the right chest measures about 
half an inch more than the left ; and vice versa. 
What is Palpation? 

The application of the hand. 

What does palpation chiefly reveal in Chest diagnosis ? 

Alterations in fremitus, and degree of respiratory 
expansion. 
How many kinds of Fremitus are there ? 

Four — (i) Vocal, (2) Tussile, (3) Rhoncal, (4) Friction. 

What is Vocal Fremitus ? 

The vibration produced by the spoken voice, com- 
municated through the lung and chest wall to the 
palpating hand. 

What is Tussile fremitus ? 

That produced by the patient coughing. 

What is Ehoncal fremitus ? 

That produced by a large rale in a bronchial tube, or 
in a cavity. 



What is Friction fremitus ? 

A fremitus produced by the rubbing together of two 
inflamed serous membranes, such as that produced 
in Pleurisy and Pericarditis. 

Where is Vocal fremitus felt over the Normal Chest ? 

Over the whole chest, except in the hepatic and car- 
diac regions anteriorly, and the two scapular regions 
posteriorly. 

What Physiological conditions increase Vocal fremitus ? 

(i) A Resonant voice, (2) A thin chest wall. 

What Pathological conditions increase Vocal fremitus ? 

Solids being a better conductor of sound than air, any 
condition which increases the solidity of the lung 
increases vocal fremitus. These are (1) Congestion 
of the lungs; (2) Croupous Pneumonia; (3) Car- 
tarrhal Pneumonia ; (4) Phthisis. 

What Physiological conditions decrease Vocal fremitus ? 

(1) A Weak voice ; (2) A thick chest wall. 

What Pathological conditions decrease Vocal fremitus ? 

(1) Obstructed bronchus ; (2) Thickened pleura ; (3) 
Effusion of air or liquid into the pleural cavity ; (4) 
Emphysema; (5) Pulmonary oedema; (6) Tumors 
of the lung. 

How can you localize small areas, in palpation ? 

By using the Ulnar edge of the hand or a Florence 
flask. 



10 

How is Vocal fremitus best elicited ? 

By having the patient repeat slowly and distinctly 
the numbers, one, two, three, or ninety-nine. 

What are the two methods of Percussion ? 

(i) Immediate or Direct, and (2) Mediate or Indirect. 
What is the object of Percussion? 

To determine Resonance, Pitch and Resistance. 

What instruments are employed in Percussion ? 

Either the fingers, or a Plexor (the hammer) and a 
Pleximeter (which receives the stroke). 

What are the disadvantages of Plexors and Pleximeters ? 

A new sound is added, and the amount of resistance 
cannot be recognized. 
How is Percussion performed ? 

The index and middle finger of the right hand are 
used as the plexor, and should be pressed firmly 
together, slightly curved, nails cut short, and finger- 
tips on a level. The motion is from the wrist, 
stroke regular, not too rapid, and is delivered against 
the middle finger of the left hand (pleximeter) just 
behind the nail. This finger must be firmly pressed 
against the chest wall, to compress the underlying 
tissues, and to recognize any abnormal resistance 
offered. 

When should the middle finger alone be used as the plexor 
in percussing ? 

In percussing superficial areas, and in children. 



II 

When may the flat of the hand be employed in direct per- 
cussion ? 

Occasionally to differentiate the two chests as a whole, 
as in catarrhal pneumonia or pleural effusion. 

What bone is sometimes used as a pleximeter ? 

The clavicle (in percussing the apex of the lung). 

What name is given to the normal percussion note obtained 
over the lungs ? 
Normal Pulmonary resonance.. 

What is the area of Normal percussion Resonance ? 

From y 2 an inch above the clavicle to the spine of the 
tenth dorsal vertebra posteriorly, and in front, as 
low as the sixth rib ; except in the praecordial region. 

What conditions will increase percussion resonance ? 

(i) Thin chest walls, (2) In children, (3) Emphysema, 
(4) Pneumothorax, (5) Empty cavities, (6) Some- 
times empty stomach (by its proximity to the lung). 

What names are given to notes more resonant than Normal 
Pulmonary Resonance % 

In their order, (1) Hyper-resonance, (2) Tympany, 
(3) Cracked-pot sound (a modified tympany). 

*|Where may thoracic Tympany be found normally ? 

(1) Trachea, (2) Left infra-axillary region, from en- 
croachment of stomach. 

* First year students are not held responsible for the questions 
preceded by the asterisk (*). 



12 

What chest diseases give Tympanitic percussion ? 

(i) Superficial Vomica, (2) Pneumothorax, (3) Rarely 
Pneumonia or Pleural Effusion (by throwing air 
into vibration, in trachea and bronchi.) 

What conditions give Cracked-pot sound ? 

(1) Cavity communicating with a bronchus ; (2) Pneu- 
mothorax with fistula of lung:. 

What names are given to percussion notes less resonant than 
normal ? 

In their order, (1) Impaired resonance, (2) Dulness 
(slight, moderate and marked), (3) Flatness. 

What conditions decrease Percussion Resonance ? 

(1) Thick chest walls; (2) Consolidation of lungs 
(Phthisis-Pneumonia); (3) Liquid exudates into 

m pleural cavity or plastic pleurisy; (4) Collapse of 
lung ; (5) CEdema and Congestion of lungs. 

What are the two methods of Auscultation ? 

(1) Immediate or direct (ear in direct contact); (2) 
Mediate or indirect (single or double stethescope 
used). 

Which stethescope is ordinarily to be preferred ? 

The single stethescope. 

What does Auscultation study in Pulmonary Diagnosis? 

(1) Breath sounds ; (2) Voice sounds (vocal Reso- 
nance) ; (3) Presence of Rales, 



13 

What is Vocal Resonance ? 

The transmission of the voice sounds through the 
lungs and chest walls, to the applied ear. 

To what is Vocal Resonance closely allied ? 

Vocal resonance in Auscultation is the analogue of 
Vocal fremitus in Palpation. 
What Physiological conditions increase Vocal Resonance ? 

(i) Resonant voice, (2) Thin chest walls. (It is nor- 
mally increased over the right apex). 

What Pathological conditions increase Vocal Resonance ? 

(1) Any consolidation of the lung; (2) Cavity. 

What Physiological conditions decrease Vocal Resonance ? 
(1) A Weak voice; (2) Thick chest walls. 

What Pathological conditions decrease Vocal Resonance ? 

(1) Obstructed Bronchus, (2) Pleural effusion, (3) Em- 
physema, (4) Pulmonary oedema. 

What are the modifications of Increased Vocal Resonance ? 

(1) Bronchophony, (2) Pectoriloquy, (3) Aegophony. 
What is Bronchophony ? 
An exaggerated Vocal resonance, seeming to come 
directly from the bronchial tube. 
What is the significance of Bronchophony ? 

It is diagnostic of the second stage of Acute Croup- 
ous Pneumonia. 
What is Exaggerated Vocal Resonance ? 
That heard over cavities and Consolidated lung. 



14 

What is Pectoriloquy? 

The Transmission of articulate words, to the auscult- 
ing ear. 

What is the significance of Pectoriloquy ? 

A cavity or Complete consolidation of the lung. 

What is the significance of whispered Pectoriloquy ? 
Always means a cavity. 

What is Aegophony ? 

A bleating or goat-like sound, produced by a thin 
layer of pleural effusion being set into vibration. 

In which stages of a pleural effusion is Aegophony heard? 

In the first and third stages. 

Of what does Respiration consist ? 

Inspiration and Expiration (Inspiration is about twice 
(Daland) or three times (Musser) as long as Expiration). 

What is the Normal Respiratory rate ? 

About 1 8. It may be as low as 14 in the aged, or as 
high as 24 in children, in health. 

What are the three Types of hreathing ? 

(1) Costal, in^women ; (2) Abdominal, in children ; (3) 
Costo-Abdominal, in male adults. 

What are the Components of the Respiratory Murmur ? 

(1) Bronchial breathing, and (2) Vesicular Murmur. 

What changes does the Normal Vesicular Murmur undergo 
in disease ? 



15 

I. Alterations in Intensity. 

(a) Increased ; as in Puerile or Vicarious breathing. 
(p) Decreased; as in Emphysema or partial occlu- 
sion of the bronchus. 
(e) Absent ; as in total occlusion of the bronchus. 

II. Alterations in Rhythm. 

(a) Cog-wheel or jerky, (as in Incipient Phthisis). 
(b~) Cheyne-Stokes breathing. 

What is Cheyne-Stokes Breathing ? 

A form of Dyspnoea consisting of a period of active 
breathing, lasting from 40 to 60 seconds, followed 
by a period of no breathing or Apnoea, lasting 10 to 
35 seconds. 

In what diseases may Cheyne-Stokes Respiration occur? 
(1) Fatty Heart ; (2) Valvular heart disease ; (3) Tuber- 
cular Meningitis; (4) Brain tumor in the region of 
the floor of the fourth Ventricle ; (5) Advanced 
Bright's Disease. 

What is the significance of Cheyne-Stokes respiration occur- 
ring in the course of Heart Disease ? 
It is usually a precursor of death. 

What are the six kinds of breathing met with in different 
forms of disease ?' 

(1) Bronchial, (2) Vesicular, (3) Broncho-Vesicular, 
(4) Cavernous, (5)Broncho-Cavernous,(6) Amphoric 



i6 

What is Bronchial breathing ? 

A high-pitched, tubular breathing ; Expiration nearly 
as long as inspiration. 

Where is Bronchial breathing heard normally ? 

Over the trachea in front and in the interscapular 
region posteriorly. 

In what diseases do we hear bronchial breathing ? 

In Pneumonia and Phthisis. 

What is Broncho-Vesicular breathing ? 

Harsher than normal, but not so harsh as bronchial 
breathing ; heard in the first stage of Phthisis. 

What is pure Vesicular breathing ? 

Softer than normal and heard in Emphysema. 

What is Cavernous breathing? 

Low-pitched, hollow, prolonged expiration, heard over 
a cavity. 

What is Broncho-Cavernous breathing ? 

Bronchial in connection with Cavernous breathing, 
heard when a cavity communicates directly with a 
bronchial tube. 

What is Amphoric breathing ? 

A low-pitched, hollow, metallic breathing, heard in 
Pneumothorax or in a lung cavity with tense walls. 

What is Puerile breathing ? 

The breathing of childhood — Expiration nearly as 



17 

long as inspiration and both acts distinctly heard. 
It is also called Exaggerated or Vicarious breathing, 
and is heard over a normal lung doing extra work. 

What is Emphysematous breathing ? 

Weak inspiration and a soft, low-pitched, prolonged 
expiration. 

What is Asthmatic breathing ? 

Expiration prolonged, wheeezing, high-pitched (Dif- 
ferentiated from bronchial breathing, by being 
universal). 



REGIONS OF THE CHEST. 



How is the chest divided horizontally by nature ? 
By ribs and interspaces. 

What is the rule for counting ribs ? 

Count the clavicle as the first rib. 

Which is the most important third of the Clavicle, from a 
medical standpoint ? 

The middle third, because the apex or the lung lies 
behind it. 
How many Sternal lines ? 

Three — Mid-sternal, and right and left sternal borders. 

What is the Parasternal line ? 

A perpendicular line drawn half way between the 
sternal border and the nipple line, (on each side). 

What is the nipple line ? 

A perpendicular line drawn from the centre of the 
clavicle parallel to the sternum. 

What is the horizontal nipple line ? 

A line drawn horizontally around the chest, passing 
through both nipples. 

How many Axillary lines ? 

Three on each side — (i) Anterior axillary line, dropped 

(18) 



«9 

perpendicularly from the junction of the anterior 
fold of the axilla with the chest ; (2) Posterior Axil- 
lary line, dropped from the posterior fold ; (3) Mid- 
axillary line, half way between these two. 

Into what regions is the lateral aspect of the chest divided ? 
Two — (1) Axillary and (2) Infra-axillary, 

What are the regions immediately above and below the 
clavicle called? 

Respectively, the Supra- and Infra-clavicular fossae. 

What is the depression at the root of the neck called ? 

The supra-sternal Notch. 

What is the lower third of the sternal region called ? 
The Ensiform region. 

What is the region about the breast called ? 

The Mammary region, (which includes the nipple 
region). 

What is the Precordial region ? 

The region in front of that part of the heart not 
covered by lung. 

How are the regions above and below the spine of the scap- 
ula named ? 
Respectively, the Supra- and Infra-Spinous fossae. 

What is the region below the shoulder-blade called ? 

The Sub-scapular region. 



20 

What area lies between the two scapulae ? 

The Inter- Scapular region. 

Name the New or Adventitious Sounds? 

(i) Rales or Rhonci. 

(2) Friction sounds. 

(3) Metallic tinkling. 

(4) Hippocratic Succussion splash. 

How are Rales divided? 

Into Dry and Moist rales. 
(For Dr. Musser's classification, see page 75.) 

How many kinds of Dry rales ? 

Two — Sibilant and Sonorous, according to the calibre 
of the tube in which they are produced. Sibilant 
rales are high-pitched dry rales, produced in small 
bronchial tubes ; sonorous rales are low-pitched dry 
rales occurring in the larger tubes. May be heard 
in inspiration, expiration, or both. 

What is the significance of Dry Rales ? 
They occur in Bronchitis and Asthma. 

How are Moist Rales divided ? 

(1) Crepitant, (2) Sub-crepitant, (3) Crackling, (4) 
Mucous, (5) Bubbling or Gurgling. 

What are Crepitant Rales ? 

A number of fine sounds occurring simultaneously at 
the end of inspiration — Pathognomonic of the first 
stage of Croupous Pneumonia, 



21 

What are Crackling Rales ? * 

A number of fine sounds occurring in succession at the 
end of inspiration — Pathognomonic of the first 
stage of Phthisis. 

What are? Sub-crepitant Rales ? 

Small moist sounds occurring in the bronchioles and 
heard in both inspiration and expiration. 

What is meant by Mucous rale ? 

A generic term for a moist rale produced by either 
mucus, blood, serum or pus. Mucous rales are large, 
medium or small, according to size. 
What are Bubbling rales ? 

The largest kind of moist rale, and may be produced 
in (i) the trachea, (2) a dilated bronchus, or (3) in 
a pulmonary or pleural cavity. 
What ate Friction sounds ? 

To and fro-friction sounds ; heard in both inspiration 
and expiration, in first and third stages of Acute 
pleurisy, and in Pericarditis, in which case they are 
synchronous with the heart-beat. 

*How can the Friction sounds of Pleurisy be distinguished 
from Sub-Crepitant rales ? 

Sub-Crepitant rales are not so superficial and are in- 
fluenced by coughing. 
What is meant by Metallic Tinkling ? 

A tinkling sound in the pleural cavity, produced by 
' the dropping of a fluid into a Hydro-pneumothorax. 



22 

What is the Hippocratic succussion splash ? 

A splashing sound heard in Hydro-Pneumothorax 

when the chest is shaken. 
What are the characteristics of the Normal Chest ? 

(i) No depression above or below the clavicle. 

(2) Both sides expand equally. 

(3) Antero-postero diameter less than the transverse. 

(4) Inferior Costal angle should be a right angle. 

(5) Scapulae should lie flat to the chest. 
What is a Phthisical Chest ? 

Long, flat chest ; ribs oblique, inferior costal angle 
acute, depression below clavicle, projecting scapulae 
forming the so-called winged or Alar Chest ? 

* What is a Rachitic Chest ? 

A pigeon chest — sternum prominent and sides flat- 
tened — bony prominences where ribs join their car- 
tilages ; called beaded ribs. 
What is the Emphysematous Chest ? 

A barrel-shaped chest. Antero-posterior diameter much 
increased ; interspaces wide ; Inferior Costal angle 
obtuse ; little expansion of chest in breathing. 

* What may cause a bulging of one side of the chest? 

(1) Vicarious emphysema. 

(2) Pleural effusion of liquid or air. 

(3) Tumors of the lung (rare). 

(4) Enlarged heart, liver or spleen. 

* What may cause Unilateral or Local Depression? 

(1) Phthisis. 

(2) Chronic pleurisy. 



PULMONARY DISEASES. 



What is Acute Bronchitis ? 

An acute inflammation of the mucous membrane of 
the larger bronchial tubes. 

What are the Physical signs of the first stage of Acute 
Bronchitis ? 

Signs negative except sonorous and sibilant rales on 
Auscultation ; little or no expectoration. 

What are the signs of the second stage ? 

Signs negative except that mucous rales replace the 
dry rales of the first stage, and the patient expecto- 
rates more or less copiously. 

* What is Capillary Bronchitis ? 

An inflammation of the smaller bronchial tubes — met 
with chiefly in children and old persons. 

* What are the signs of Capillary Bronchitis ? 

Inspection, Alae of nose play ; sterno-mastoid muscles 
prominent ; Supra-sternal notch deep ; base of chest 
sucked in. 

Palpation and Percussion negative. 

Auscultation. Sibilant rales first, followed by sub- 
crepitant rales over bases of lungs. 

(23) 



2 4 

* What is apt to be the sequel of long-continued Bronchitis ? 

Emphysema or Bronchiectasis (dilatation of tubes), 

How many forms of Pneumonia are there ? 

(i) Croupous or Lobar, and (2) Catarrhal, Lobular or 
Broncho-Pneumonia. 

What is acute Croupous Pneumonia ? 

An acute inflammation of the lungs. 

What is the exciting cause of Croupous Pneumonia ? 

The Pneumonococcus and extravasation of blood. 

How many stages has Croupous Pneumonia ? 

Three; (1) Congestion, (2) Consolidation or Red 
Hepatization, and (3) Resolution or Grey Hepatiza- 
tion. 

What is the Morbid Anatomy of these Three stages ? 

First stage. Lung is congested, less crepitant and a 
little heavier than normal ; no exudate. 

Second stage. Red, heavy and solid ; vesicles filled 
with exudation of plasma. 

Third stage. Lung is less solid and yellowish from 
fatty degeneration of the exudate. 

What are the physical signs of the First stage ? 

Inspection. Dyspnoea, flushed cheek, rusty sputum, 
accelerated respiration and heart-beat. 

Palpation. Increased fremitus and decreased expan- 
sion. 



25 

Percussion. Impaired resonance. 
Auscultation. Crepitant rales. 

What are the signs of the Second stage ? 

Inspection. Same as first stage except respira tion is 
more rapid, and no expansion. 

Palpation. Increased fremitus and absent expansion. 

Percussion. Fixed dulness marked and sense of resist- 
ance to finger noted. 

Auscultation. Bronchial breathing and Bronchophony, 
no rales. 

What are the signs of the Third stage ? 

Same signs, except on auscultation breath sounds a 
little softer and moist rales are present in consider- 
able number, due to liquefaction of the exudate. 
(First sub-crepitant then mucous rales.) 

What is Catarrhal or Broncho-Pneumonia ? 

An inflammation of the terminal bronchioles and 
alveoli. 

What is the cause of Catarrhal Pneumonia ? 

From extension of a bronchitis into the air vesicles ; 
or by the desquamation of epithelium. 

What is the morhid anatomy of Catarrhal Pneumonia ? 

A bilateral disease, giving scattered areas of consoli- 
dation through both lungs. 

What are the signs of Catarrhal Pneumonia ? 

Like those of Croupous Pneumonia, buf less marked, 



26 

and sub-crepitant rales replace the crepitant of 
croupous^ and the areas of consolidation are scat- 
tered and less defined. 
What is the frequency of Tuberculosis as a cause of death ? 
One out of seven deaths is due to this process, which 
may affect almost any tissue in the body. 

What is the exciting cause of Tuberculosis of the lungs ? 
The tubercle bacillus, which enters the body through 
respiration, digestion or direct inoculation. 
How many stages has Phthisis ? 

Three ; (i) Infiltration, (2) Consolidation, (3; Soften- 
ing and Cavity formation. 
What is the Morbid Anatomy of these three stages? 
First stage. Scattered grey tubercles at apex, size of 

a millet seed. 
Second stage. Cheesy infiltration forming a soft mass 
from tubercles running together and undergoing a 
fatty degeneration. 
Third stage. Softening and the formation of cavities. 
*What are the types of Phthisis ? 
(1) Catarrhal and (2) Fibroid. 
*What are the characteristics of Catarrhal Phthisis? 
It is a catarrhal pneumonia in conjunction with the 
tubercle bacillus. 
*What is Fibroid Phthisis ? 

Phthisis in which there is great overgrowth of connec- 
tive tissue. 



27 

* What is Phthisis Florida ? 

Galloping Consumption, in which from the beginning 
large areas of the lungs are involved in catarrhal 
phthisis and the disease runs a rapid fatal course. 

What are the signs of the First stage of Phthisis ? 

Inspection, Negative; or perhaps a phthisinoid chest. 
Palpation. Slightly increased fremitus. 
Percussion. Impaired resonance, high pitched. 
Auscultation. Slightly K increased vocal resonance; 
Broncho-vesicular breathing ; Crackling rales. 

What are the signs of the Second stage ? 

Inspection. Diminished expansion, Dyspnoea, and 

prominent cavicle. 
Palpation. Increased fremitus, decreased expansion. 
Percussion. Dulness. 
Auscultation. Bronchial breathing and increased vocal 

resonance. Mucous rales. 

What are the signs of the Third stage ? 

Inspection. Dyspnoea; Emaciation; Absent expan- 
sion and Phthisical chest. 

Palpation. Vocal fremitus, usually decreased ; Ab- 
sent expansion. 

Petcussion. Local tympany and sometimes cracked- 
pot sound. 

Auscultation. Cavernous breathing, Pectoriloquy and 
bubbling rales usually. 



28 

When may no rales be heard over a cavity ? 

(i) If cavity is empty. 

(2) If completely filled. 

(3) If no air enters, from obstruction of bronchus. 
What is the expectoration of Phthisis ? 

Heavy greenish-yellow nummular (coin-shaped) spu- 
tum containing tubercle bacilli, fibro-elastic tissue 
and cheesy particles. Sinks in water. 
What is Acute Miliary Tuberculosis ? 

An acute general tubercular disease of the lungs (and 
other tissues) usually fatal in two to four weeks. 

What are the Physical signs of this disease ? 

Very unsatisfactory. Inspection: Fever, Dyspnoea, 
Cough and expectoration. — Palpation and Percus- 
sion negative. Auscultation; negative, or perhaps a 
fewbronchitic rales, usually sibilant or sub-crepitant. 
What is Pulmonary Emphysema ? 

A permanent over-distension of the air-cells of the 
lungs. 
*How is Emphysema of the lungs divided? 

(1) Interlobular; (very rare) air in the interstitial tis- 
sue of the lungs from rupture of air vesicles. 

(2) Vesicular, which is increased air in the lungs with 
dilatation of the vesicles. 

What are the varieties of the Vesicular form ? 

1. Compensatory or Vicarious — when one lung or a 
part of it is doing extra work, 



29 

2. Atrophic — occurring in old people, from atrophy of 
the solid tissue of the lungs. 

3. Hypertrophic (most important) — a bilateral disease 
due to overstretching of the vesicles. 

What is the cause of Emphysema ? 

Strained expiration (as in (1) Chronic bronchitis ; (2) 
Asthma ; (3) Certain occupations ; as glass-blowers, 
cornet-players,, etc.). 

What is the anatomy of Emphysematous lungs? 

Lungs are large, pale and often show large bullae on 
their free margins. Feel like cotton, being soft 
and spongy, and show marks of the ribs. 

What are the physical signs of Emphysema? 

Inspection. Emphysematous or barrel-shaped chest. 

Palpation. Diminished fremitus. 

Percussion. Universal hyper-resonance, with decreased 
or absent cardiac, splenic and hepatic dulness. 

Attscultation. Diminished vocal resonance, weak in- 
spiration, and prolonged low-pitched or inaudible 
expiration. 
What is Asthma ? 

Paroxysmal dyspnoea, due to spasm of the bronchial 
tubes. 
What are the varieties of Asthma ? 

(1) Essential or Idiopathic ; (2) Bronchitic, due to 
inflammation of bronchial tubes ; (3) Cardiac ; (4) 
Renal ; (5) Reflex (hay or catarrhal asthma). 



30 

What are the signs of Asthma ? 

Inspection. Intense dyspnoea and little expansion. 
Palpation and Percussion negative. 

Auscultation. Sonorous and sibilant rales, short in- 
spiration and prolonged, high-pitched, wheezing ex- 
piration heard over the whole chest. 



PLEURAL AFFECTIONS. 



How many stages has acute Pleurisy ? 

Three, (i) Dry stage — membranes red, sticky and 
lustreless. 

(2) Stage of Effusion — which may be (a) serous (hy- 
drothorax) ; (b) Purulent (empyema or Pyothorax) ; (c) 
Fibrinous (plastic pleurisy). 

(3) Stage of Absorption (when effusion is serous). 

What are the signs of the first stage of Acute Pleurisy? 

Inspection. Restricted expansion (from pain) and 
dyspnoea ; patient favors affected side. 

Palpation. Diminished expansion and occasionally a 
friction fremitus is felt. 

Percussion. Negative except sound lung is hyper- 
resonant from vicarious work. 

Auscultation. Weak breathing with a to-and-fro fric- 
tion rale, superficial and synchronous with respira- 
tion. 

What are the signs of the second stage with serous effusion ? 

Inspection. No pain ; bulging of interspaces ; dimin- 
ished expansion ; dyspnoea ; displaced apex-beat. 
Lies on affected side. 

Palpation. Diminished fremitus ; displaced apex-beat. 

Percussion. Movable dulness (hydrostatic test). Above 
level of liquid hyper-resonance (Skoda' s resonance). 

(31) 



32 

Auscultation. Weak or absent breath sounds below 
liquid and bronchial breathing posteriorly over 
bronchus. Vocal resonance absent, or if effusion be 
small, aegophony, best heard at angle of scapula. 

What are the signs of the stage of Absorption ? 

Breath sounds, vocal fremitus and resonance, segoph- 
ous and friction sounds return ; and area of movable 
dulness gradually disappears. 

* How can Pyothorax or purulent effusion be recognized ? 

(i) Occasionally there is pitting on pressure ; (2) By 
Aspiration ; (3) Symptoms of Hectic fever. 

* What are the signs of Plastic Pleurisy ? 

Inspection. No bulging of interspaces or displace- 
ment of apex-beat, but later a retraction of the 
chest. 

Palpation. Diminished fremitus. 

Percussion. Fixed dulness. 

Auscultation. Weak breathing ; diminished vocal re- 
sonance, friction rale may still be heard ; pain con- 
tinues, and needle gives a negative result. 

What is Pneumothorax ? 
Air in the pleural sac. 

What are the causes of Pneumothorax ? 
J^(i) Rupture of lung into pleura (from abscess, phthi- 
sical cavity or emphysema). 



33 

(2) Traumatism of any kind (as stab or gunshot 
wounds). 

(3) Rupture of an empyema. 

What are the physical signs of Pneumothorax ? 

Inspection. Intense dyspnoea (40 to 50 per minute) ; 
bulging of interspaces ; immobility of chest ; dis- 
placed apex-beat. 

Palpation. Expansion and vocal fremitus absent. 

Percussion. Unilateral tympany ; and percussing with 
silver coins yields " Bell tympany " (on auscultation). 

Auscultation. Breath sounds and vocal resonance 
weak or absent ; amphoric breathing (if fistula is 
patulous). Amphoric pectoriloquy. 

From what must Pneumothorax be differentiated ? 

(1) Emphysema, which is bilateral, and the percussion 
note is only hyper-resonant and not tympanitic. 

(2) Dilated stomach, in which case the tympany does 
not extend so high, and when the patient is allowed 
to swallow water it can be distinctly heard trickling 
into the stomach. 

What is usually the sequel of Pneumothorax ? 
Hydro-pneumothorax or Pyo-pneumothorax. 

What is meant by Hydro-pneumothorax and Pyo-pneumo- 
thorax ? 

Hydro-pneumothorax is both serum and air in the 

pleural cavity. 
Pyo-pneumothorax is pus and air in the pleural cavity. 



34 

What are the signs of Hydro-pneumothorax ? 

Inspection. Bulging; immobility of chest and dis- 
placed heart. 

Palpation. Diminished or absent fremitus ; immobil- 
ity ; displaced heart, and spleen or liver. 

Percussion. Freely movable dulness (hydrostatic 
test) above liquid, tympany and Bell tympany (coin 
test). 

Auscultation. Absent breath sounds; amphoric pec- 
toriloquy (if fistula present) and amphoric breath- 
ing ; hippocratic succussion splash (pathognomonic) 
metallic tinkle, and " Bell tympany " with silver coin 
percussion. Bubbling rales. 

What are the signs of Pyo-Pneumothorax? 

Same as in hydro-pneumothorax with also signs of 
hectic fever and pitting on pressure. Aspiration 
confirms the diagnosis. 



CARDIAC DIAGNOSIS. 



Describe the circulation of the blood ? 

The venous blood is returned from the body by the 
two Venae cavae to the Right Auricle, where it 
passes through the Tricuspid orifice into the Right 
Ventricle. The contraction or systole of the Right 
Ventricle forces the blood past the Pulmonary Semi- 
lunar valves, and through the Pulmonary Arteries to 
the lungs, where it is aerated and then returned to 
the Left Auricle by means of the Pulmonary veins. 
It then passes through the Mitral orifice to the Left 
Ventricle, the contraction of which sends it past 
the Aortic Semi-lunar valves into the Aorta and 
thence throughout the general system. 

What is the Heart? 

A hollow muscular organ, acting as a duplex pump, 
and containing four cavities. 

What is the size of the normal Heart ? 

Roughly, it is stated to be the size of the individual's 
clenched fist. 

What is the average weight of a normal Heart ? 
Eight to ten ounces. 

(35) 



36 

What is the normal position of the Apex-beat ? 

In the fifth interspace one inch within the nipple line. 
(In children it may be as high as the fourth inter- 
space ; and in the aged as low as the sixth.) 

What factors are to be noted in regard to the Apex-beat ? 

(i) Position. (2) Extent. (3) Force or intensity. 

How may the Apex-beat be brought out ? 

(1) Exercise. (2) Inclining the body forward and to 
the left. (3) Deep expiration. 

* What may displace the Apex-beat toward the right? 

(1) Hypertrophy and dilatation of Right Ventricle. 

(2) Left-sided pleural effusion. (3) Contracting 
right lung disease. 

* What may displace the Apex-beat toward the left ? 

(1) Hypertrophy, or (2) Dilatation of Left Ventricle. 

(3) Pericardial effusion. (4) Right-sided pleural 
effusion. (5) Abdominal tumors or dropsies. (6) 
Contracting left lung disease. 

* What may displace the Apex-beat downwards ? 

(1) Cardiac Hypertrophy and Dilatation; and (2) 
Emphysema of lungs. 

* What increases the force of the heart-beat? 

(1) Thin chest walls ; (2) Excitement; (3) Emotions; 

(4) Stimulants ; (5) Exophthalmic goitre ; (6) 
Hypertrophy. 



37 

* What diminishes the force of the Apex-beat ? 

(i) Thick chest walls ; (2) Emphysema ; (3) Peri- 
cardial effusion ; (4) Dilatation ; (5) Fatty degener- 
ation. 

* What increases the extent of the Apex-beat ? 

(1) Excitement; (2) Thin chest walls; (3) Phthisis; 
(4) Hypertrophy. 

* What may produce a thrill over the Apex ? 

(1) Pericardial adhesion; (2) Aneurism (most com- 
mon) ; (3) Mitral disease. 

What are the areas of Cardiac dulness ? 

(1) Superficial (representing the uncovered part of 
the heart), and (2) Deep (whole area). 

What is the triangle of Superficial dulness ? 

Hypothenuse of triangle from fourth left costo-sternal 
junction to apex-beat. Perpendicular of triangle 
formed by left border of the sternum. Base line, 
from apex of heart (fifth interspace within nipple 
line) horizontally toward right to left sternal border. 

What is the normal area of deep Cardiac dulness ? 

From third left costo-sternal articulation to apex-beat ; 
thence to right sternal border, and up right sternal 
border to third rib. 

Where is the Mitral Area? 

A circle one inch in diameter, corresponding to the 
apex region. 



38 

Where is the Tricuspid Area? 

A circle one inch in diameter at the ensiform cartilage. 

Where is the Pulmonic Area ? 

At the second left costal cartilage. 

Where is the Aortic Area ? 

At the second right costal cartilage. 

* What causes increase the area of Cardiac dulness ? 

(i) Thin subjects; (2) Fibroid Phthisis ; (3) Hyper- 
trophy ; (4) Dilatation, (5) Pericardial effusion (tri- 
angle of dulness reversed). 

* What causes decrease the area of Cardiac dulness ? 

(1) Thick chest walls ; (2) Emphysema ; (3) Pneumo- 
thorax. 

What are the two sounds of the heart ? 

Systolic or First sound (heard best at apex), and Dias- 
tolic or Second sound, heard best at Aortic Carti- 
lage). (These sounds are imitated by the words 
Lub-dup.) 

What are the causes of the First sound ? 

(1) Contraction of the heart muscle. 

(2) Striking of the heart against the chest wall. 

(3) Closure of the Auriculo-Ventricular valves. 
(These factors can only be distinguished in disease.) 

What is the cause of the second sound ? 

Closure of the semi-lunar valves (Aortic and Pulmo- 
nary.) (Diastolic in time, and can be distinguished 



39 

from each other in health, the Aortic being louder 
than the Pulmonary.) 

* What causes increase the heart sounds? 

(i) Excitement; (2) Thin chest walls; (3) Hyper- 
trophy; (4) Retraction of the lungs. 

* What causes decrease the heart sounds ? 

(1) Thick chest walls ; (2) Emphysema; (3) Pericar- 
dial effusion; (4) Constitutional weakness (after 
disease) ; (5) Fatty degeneration of heart muscle. 

What is Endocarditis ? 

Inflammation of the lining membrane of the heart ; 
affects chiefly the valves. (Called valvulitis.) 

What are the causes of Endocarditis ? 

(1) Rheumatism (most frequent) ; (2) specific fevers ; 
(3) Syphilis; (4) Alcoholism; (5) Bright' s disease; 
(6) Pyaemia ; (7) Excessive straining (may produce 
Aortic regurgitation). 

What are the varieties of Endocarditis ? 

(1) Vegetative; (2) Interstitial (most common); (3) 
Ulcerative or malignant (rare) (due to pyaemic 
micrococci). 

What lesions does Endocarditis produce ? 

Either Valvular obstruction or Regurgitation, or both. 

Which valve is most commonly affected ? 

The Mitral Valve. 



40 

To what new sounds do these lesions give rise ? 

Organic heart murmurs. 

From what must Organic murmurs be distinguished ? 
From Functional or Haemic murmurs. 

What are the chief points in this differential diagnosis ? 
(See table, page 74.) 

What three factors determine the diagnosis of any particular 
valvular murmur ? 

(1) Time of murmur. 

(2) Point of maximum intensity. 

(3) Direction in which the murmur is transmitted, 

How do you make the diagnosis of Mitral Obstruction ? 

(1) Presystolic in time; (2) Point of maximum 
intensity, one inch above apex ; (3) Not transmitted. 

What are the diagnostic signs of Mitral Regurgitation ? 

(1) Systolic murmur ; (2) Heard loudest at apex ; 
and (3) transmitted into left Axilla (and if loud 
enough, to angle of left scapula also). 

How can you diagnose Aortic Obstruction ? 

(1) Systolic murmur ; (2) loudest at Aortic Cartilage 
(second right costal cartilage) ; (3) transmitted into 
the Carotid Artery. 

How is the diagnosis of Aortic Regurgitation made? 

(1) Diastolic murmur ; (2) loudest at Aortic Cartilage ; 
(3)-transmitted down the sternum. 



41 

What is the special sign of Aortic Regurgitation ? 

The Corrigan or water-hammer pulse ; which is a quick, 
full and receding pulse. 

What are the signs of Tricuspid Regurgitation ? 

(i) Systolic murmur; (2) best heard over mid-sternum ; 
(3) transmitted toward epigastrium. 

What is the special sign of Tricuspid Regurgitation ? 

Pulsation of Jugular Vein, and in bad cases pulsation 
also in the liver. 

What are the signs of Tricuspid Stenosis or Obstruction ? 

(1) Presystolic murmur; (2) best heard at mid-sternum ; 
(3) not transmitted. 

What are the signs of Pulmonary Obstruction ? 

(1) Systolic murmur; (2) loudest at Pulmonic cartilage 
(second left costal cartilage) ; (3) transmitted into 
Pulmonary artery. 

What are the signs of Pulmonary Regurgitation ? 

(1) Diastolic murmur; (2) loudest at Pulmonic carti- 
lage y (3) transmitted down the sternum. 

What is the frequency of Pulmonary and Tricuspid mur- 
murs ? 

All very rare. Pulmonary murmurs are congenital, 
and Tricuspid murmurs either congenital (if pri- 
mary) or secondary to mitral murmurs. 

What is meant by Compensation being established ? 

Increased strength of heart to overcome obstruction 



42 

and make up for extra work, due to enlargement of 
heart cavity. 

What are the chief affections of the Heart-muscle or Myocar- 
dium? 

(i) Hypertrophy; (2) Dilatation; (3) Fatty degenera- 
tion. 

What is Hypertrophy of the Heart ? 

An Enlargement of the heart-muscle. 

What three forms of Hypertrophy are recognized ? 

(1) Simple, walls thicker, without change in size of 
cavity. 

(2) Concentric, walls thicker, and cavity smaller than 
normal. (Only a post-mortem condition). 

(3) Eccentric, walls thicker and cavity larger than 
normal. 

What part of the heart is most frequently hypertrophied ? 

The left ventricle. 

What are the causes of Hypertrophy of the Left Ventricle ? 

Any obstruction to the systemic circulation of the 
blood (such as arterial atheroma and Bright's 
disease). 

What are the signs of Hypertrophy of the left heart ? 

Inspection. Forcible apex-beat displaced both down- 
ward and to the left. 
Palpation. Confirms inspection. 



43 

Percussion. Area of cardiac dulness increased down- 
ward and to left. 

Auscultation. Over apex, first sound stronger than 
normal and second sound accentuated (due to 
increased tension). 

What is Dilatation of the heart ? 

An enlargement of the heart due to a stretching of the 
heart-muscle, causing an increase in the size of the 
cavity. 

What are the causes of cardiac dilatation ? 

(i) Sudden increase in endocardial pressure. 
(2) Degeneration of the heart muscle. 

What are the signs of Dilatation of the heart ? 

Inspection and Palpation. Apex-beat diffuse and weak, 

or in extreme cases invisible. 
Percussion. Gives increased area of dulness to left. 
Auscultation. First sound weak, or in extreme cases 

valvular, like the second sound ; often a murmur from 

mechanical stretching of orifice, rendering valve 

incompetent. 

What are the two forms of Fatty Heart ? 

(1) Fatty Infiltration (occurring chiefly in obesity). 

(2) Fatty Degeneration. 

What are the signs of Fatty Infiltration of the Heart? 

Dyspnoea ; Weak pulse and heart sounds ; Feeble im- 
pulse of heart associated with obesity. 



44 

What are the signs of Fatty Degeneration of the Heart ? 

Inspection. Apex-beat feeble and irregular or absent. 

Palpation. Confirms. 

Percussion. Area of Cardiac dulness normal. 

Auscultation. First sound of heart weak or even val- 
vular. 
* What are the symptoms of Fatty Degeneration of Heart ? 

Same as in Valvular disease with lost compensation. 
What is Angina Pectoris ? 

An agonizing paroxysmal cardiac pain, radiating to 
the left shoulder and down the left arm, and accom- 
panied by a sense of impending death. 

What is Angina Pectoris also called? 

Breast Anguish. 

Angina Pectoris is usually associated with what disease ? 

Either Valvular disease, or Fatty degeneration. 

What is Pericarditis ? 

An inflammation of the serous membrane covering 
the heart (called the Pericardium). 

What are the three kinds of Pericarditis ? 

(i) Serous (usual form); (2) Plastic ; (3) Purulent. 

What are the causes of Pericarditis? 

Same as in Pleurisy. (Rheumatism most frequently.) 

What are the stages of Acute Pericarditis ? 

First stage, Inflammation ; Second stage of Effusion ; 
Third stage of Absorption. 



45 

What are the signs of the first stage ? 

Inspection. Accelerated apex-beat in normal position. 

Palpation. In some cases, a to-and-fro friction fremi- 
tus, and tenderness on pressure. 

Percussion. Negative. Area of dulness not increased. 

Auscultation. A superficial to-and-fro friction sound 
synchronous with the heart-beat, heard best over 
base, and not transmitted. 

What are the signs of the Second Stage ? 

Inspection. Absent apex-beat ; Bulging praecordia and 
intercostal spaces ; Dyspnoea. 

Palpation. Confirms inspection. 

Percussion. Increased area of dulness, triangular in 
shape, with base down (movable dulness usually 
present). 

Atiscultation. Heart sounds feeble, distant and muf- 
fled ; no friction sound. 

What are the signs of the stage of Absorption ? 

Apex-beat reappears, area of dulness decreases and 
friction sound returns. 

What are the signs in the second stage, if the effusion be 
Purulent ? 

Same signs as in serous effusion, but also Hectic 
fever is present and the aspirating needle shows 
pus. 



46 . 

What are the signs of the second stage, if the effusion be 
Plastic ? 
Apex not much displaced ; pulsation is wavy over 
whole heart ; praecordia shows dimpling, and friction 
sounds persist. 

What is Paracentesis Pericardii ? 

Tapping the pericardial effusion ; (fifth interspace 
usually selected). 

What is an Aneurism ? 

The local dilatation of one or more coats of an artery. 

What is the most common site of an Aneurism ? 
The Arch of the Aorta. 

What are the ordinary forms of Aneurism ? 

(i) Fusiform; (2) Cylindrical; (3) Sacculated (4) Dis- 
secting. 

How does an Aneurism heal? 
By laminated clots. 

What are the causes of Aneurism ? 

(1) Injury or strain ; and (2) Atheroma. 

*What are the causes of Atheroma of an artery ? 

(1) Syphilis ; (2) Rheumatism ; (3) Gout ; (4) Alcohol ; 
(5) Bright's disease ; (6) Old age. 

What are the physical signs of an Aneurism ? 

Inspection. Local bulging with pulsation. 
Palpation, Expansile pulsation and thrill, 



47 

Percussion. Localized dulness. 

Auscultation. Systolic Bruit or murmur, and second- 
arily, accentuated heart sounds. 

What are the pressure symptoms of Aneurism of the Aortic 
Arch? 

(i) Dyspnoea ; (2) Dysphagia ; (3) Weak or Absent 
breathing on affected side ; (4) Aphonia or Laryn- 
geal cough ; (5) Unequal Pupils ; (6) Unequal radial 
pulses ; (7) GEdema of one side of neck with cya- 
nosis ; (8) Boring intercostal pain worse at night ; 
(9) Progressive loss of flesh and strength (if tho- 
racic duct is pressed upon) ; (10) Unilateral sweat- 
ing of the face (from pressure on Cervical sym- 
pathetic). 

"What is Grave's or Basedow's Disease ? 

Exophthalmic Goitre. 

*What is the cause of Exophthalmic Goitre ? 

A functional or organic disease of the Cervical sym- 
pathetic ganglia. 

*What are the symptoms of Exophthalmic Goitre ? 

(1) Bulging eye-balls (from congested sockets) ; with 
paresis of the upper lids. 

(2) Enlarged pulsating thyroid gland, gives a thrill 
on palpation and a Bruit on Auscultation. 

(3) Palpitation of the heart leading to hypertrophy. 



THE PULSE. 



What is the Pulse ? 

The recognition of the variation in the size of an 
artery. 

How is the pulse palpated ? 

By using the index, middle and ring fingers. 

Why should the thumb not be used ? 

Because it is too broad and has a pulse of its own. 

How is the pulse counted ? 

In ordinary cases, count for fifteen seconds and mul- 
tiply by four to get the rate per minute. For ac- 
curacy count a full minute. 

What is the normal Pulse-rate in an adult male ? 

Average is 72, but it may vary from 11 to no consist- 
ent with health. The average variation is 12 to 15 
beats in health. 

How can a very rapid pulse be counted ? 

By marking dots on paper with a lead pencil and after- 
ward counting the dots. 

Can the radial wall be felt in health ? 

No. 

(48) 



49 

What are the most frequent causes of thickened arterial 
walls? 

(i) Age, (2) Alcohol and (3) Syphilis. 

What factors are to be noted in studying the Pulse ? 

(1) Condition of the Arterial wall. 

(2) Size or volume of Pulse (whether large or small). 

(3) Rate (rapid or slow). 

(4) Rhythm (whether regular, irregular, intermittent 
or lagging). 

(5) Force (increased or decreased). 

(6) Tension (high or low) means intra-vascular 
pressure. 

(7) Quality or length of the wave (short or long). 

What effect has fever on the Pulse-rate ? 

Accelerates it about ten beats for each degree of fever, 
except in scarlet fever, when the acceleration is 
much greater in proportion to the temperature. 
What is Tobacco heart ? 

A functional disturbance of the heart, usually associ- 
ated with palpitation. Rate from 90-110. 

What conditions may cause a slow pulse ? 

Icterus, Uraemia, Fright, Drugs, Age, Fatty de- 
generation of the heart (here it is also irregular and 
intermittent). 
What may cause an irregular heart-beat? 

Emotions, Alcohol, tea, coffee, tobacco, Fatty degener- 
ation. 



So 

Upon what does the Force of the pulse depend? 

Upon the strength of the heart and the size of the 
capillaries. 

What instrument is used for taking pulse tracings ? 

The sphygmograph — a small instrument strapped upon 
the wrist. The beat of the pulse pressing upward 
upon a short lever, communicates its motion to a 
longer arm, the distal end of which traces the pulse 
wave upon a strip of blackened paper. 

What is the pulse tracing called ? 

The sphygmogram. 

What are the parts to a normal pulse tracing ? 

(i) Primary wave ; (2) Secondary wave; (3) Aortic 
notch; (4) Dicrotic wave. 



ABDOMINAL DIAGNOSIS. 



Which are the most important methods in Abdominal Diag- 
nosis ? 
Palpation and Percussion. 

How is the Abdomen divided for convenience in study ? 
Into nine regions ; formed by drawing two horizontal 
lines (one on a line with the crests of the iliac 
bones, the other parallel with the cartilages of the 
ninth ribs) and two perpendicular lines (one on each 
side from the cartilage of the eighth rib to the centre 
of Poupart's ligament). 

What are the names of these nine regions ? 

Upper zone. Epigastric (in the middle) and right and 

left hypochondriac. 
Middle zone. Umbilical (middle) and right and left 

lumbar. 
Lower zone. Hypogastric (middle) and right and left 

iliac or inguinal. 

What is the position of the normal spleen ? 

In the left hypochondriac region, between the ninth 
and eleventh ribs (in the mid-axillary line). 

(SO 



52 

How should the spleen be palpated ? 

Use the flat of the hand and direct the patient to 
deeply expire, followed by an inspiration, which 
pushes the spleen against the hand and if enlarged, 
its edge may be felt. 

Where is the Liver situated ? 

In the right hypochondriac region, extending from the 
fifth rib above (in the nipple line) to the margin of 
the ribs below. 

How can the size of the stomach be obtained ? 

Have the patient swallow some water and then by 
percussion ascertain the outer limits of movable 
dulness, in connection with the gastric tympany. 

What is washing out the stomach called ? 

Lavage. 
How is this accomplished ? 

By means of the stomach pump or the syphon bottle. 

What is forced feeding through a stomach tube called ? 

Gavage. 
In what disease of the stomach is Hydrochloric Acid absent ? 

In Gastric Cancer. 
In what disease of the stomach is this Acid increased ? 

In Gastric Ulcer. 

How can you test for Hydrochloric acid in the gastric juice? 

Congo red paper is turned blue (only by hydrochloric 
acid). 



53 

What is another test for gastric Hydrochloric Acid ? 

One drop of a six per cent, solution in alcohol of 
Phloro-Glucin-Vanillin (equal parts) added to one 
drop of the gastric juice will show a rose-red color 
on a porcelain dish, gently heated. 

How do you test the gastric juice for Pepsin? 

Place a small bit of coagulated egg albumen in a test- 
tube with some of the gastric juice containing HC1 
and place in a warm oven (ioo°F.). If pepsin is 
present in normal quantity the albumen will be 
digested in a few hours. 

How can you test the rapidity of Absorption in the stomach ? 

Give Iodide of Potash in capsule and note how long 

before it appears in the saliva (by testing saliva with 

starch paper and sulphuric acid (one drop), which 

gives a blue color). 

How can you tell when the food passes from the stomach 
into the intestines ? 
Give Salol in capsule, which is only broken up by the 
intestinal juices, liberating Salicylic acid, which is 
tested for in the urine by a ferric salt (Fe 2 Cl 6 ) 
giving a blue color. 

What may cause abdominal Distension ? 

(i) Ascites; (2) Tympanites ; (3) Pregnancy; (4) En- 
largement of any organ ; (5) Distended bladder. 



54 

What is Meteorism ? 

A moderate gaseous distension of the abdomen, rec- 
ognized by percussion. 
What is Tympanitis ? 
Marked gaseous distension of the abdomen, recognized 
by percussion. 

What is a Scaphoid Abdomen? 
One that is concave. 

In what conditions is a Scaphoid Abdomen found ? 

(i) In wasting diseases, as cancer, etc. 
(2) In Tubercular Meningitis. 

What is Ascites ? 

Dropsy of the peritoneal cavity. 

What are the most common causes of Ascites ? 

Chronic disease of the (1) Kidneys, (2) Heart, or (3) 
Liver (especially). 

What are the Physical signs of Ascites ? 

Inspection. Uniform distension with tendency to sag- 
ging of the flanks. 

Palpation. A sense of resistance and fluctuation. 

Percussion. Umbilical region resonant and movable, • 
dulness in flanks. 

Auscultation. Negative. 

How can you differentiate between Suppression and Reten- 
tion of Urine? 
By percussion, which gives dulness if retention ; reso- 



55 

nance if suppression — corroborated by passing a 
catheter. 

What is the position of the Kidneys ? 

In the lumbar regions, behind the peritoneum, extend- 
ing from the eleventh rib, nearly to the crest of the 
Ilium. The right kidney is lower than the left on 
account of its proximity to the liver. 

How are the kidneys best palpated? 

By bi-manual palpation — one hand under the back of 
the patient in the supine position, the other palpa- 
ting in front with the knees drawn up. 

What is the best method for percussing the Kidneys? 
Patient prone, pillow under abdomen ; percuss forci- 
bly on each side of lumbar spine. 

How is temperature taken ? 

By the clinical thermometer placed in the (i) mouth 
(4 minutes), (2) Axilla (8 minutes), or (3) Rectum 
(4 minutes). Keep the thermometer aseptic. 

Is the temperature the same in these three places ? 

No. Temperature in the rectum is about y 2 degree 
higher than in the mouth, and this is about y 2 degree 
higher than in the axilla. 



BLOOD. 

(For First Year men.) 



What is blood? 

The liquid tissue of the body. 

Of what does it chiefly consist ? 

Plasma and Corpuscles (red and white). 

How much blood is there in the human body? 

About one-thirteenth of the body weight. 

Which corpuscle is the larger ? 

The white. 

What is the size and shape of the red corpuscle ? 

A biconcave circular disc about ^oVo °f an i* 10 * 1 i n 
diameter. 

What is its function ? 

To carry oxygen to the tissues and return carbonic 
oxide to the lungs. 

To what is its red color due ? 

To the presence of Haemaglobin, the most complex 
molecule known. 

What is the normal Specific Gravity of the blood ? 

About 1060. 

(56) 



57 

Upon what does the specific gravity of the blood chiefly 
depend ? 

Upon the amount of hsemaglobin present. 

How can you determine the specific gravity of the blood ? 

Fill several test tubes with mixtures of different pro- 
portions of glycerine and water, the specific gravity 
of each mixture being known. A jet of blood 
thrown from a capillary glass tube attached to the 
nozzle of a hypodermic syringe will be suspended in 
equilibrium, in that mixture whose specific gravity 
corresponds with that of the blood. 

What is the best instrument for counting blood corpuscles ? 
The Thoma-Zeiss Haemocytometer. 

Of what parts does this instrument consist ? 

(i) A graduated capillary pipette with an ampulla or 
dilatation in its upper third, containing a glass bead 
and (2) a graduated microscopic slide. The pipette 
is marked at three points, viz : o .5 ; 1, and 101. The 
field of the slide is divided into sixteen larger 
squares, each containing sixteen smaller squares. 
The capacity of each smaller square is ^V °f a 
cubic millimeter. 

What is the best diluting fluid for counting red corpuscles ? 
t ^Two and a half per cent, solution of Bichromate of 

Potassium. 
What are the advantages of this liquid ? 
Three. (1) Fixes shape and color of the red corpuscle ; 



58 

(2) Prevents coagulation ; (3) Prevents the formation 
of rouleaux. 

From where is the drop of blood obtained ? 

Preferably from the tactile surface of the thumb or 
lobe of the ear. 

When do we select the lobe of the ear ? 

When the epidermis of the finger is thick and horny. 

How is the skin previously cleansed ? 

By washing successively with soap, alcohol and ether. 

How is the puncture made ? 

A quick thrust with a Hawksley sticker or a large 
needle. 

What is the next procedure ? 

Place the point of the pipette in the drop of blood, 
and by aspiration suck the blood up to the point 
marked one. Wipe off the excess, and placing the 
pipette in the bichromate solution, fill to the point 
marked 10 1. Mix thoroughly by shaking the pipette 
for at least one minute ; then blow out the last por- 
tion of the fluid sucked up, and place a small drop 
of the blood mixture upon the graduated slide. 

How is the cover-glass placed in position ? 

Do not drop it on, but slide it on, to avoid the admis- 
sion of any air-bubbles. If there is any air in the 
mount, it must be repeated, after carefully cleansing 
both slide and cover-glass. 



59 

• 

How is the count made ? 

Count the number of corpuscles in each of sixty-four 
small squares. Multiply the sum of these by ioo 
for the dilution and then by 4,000 for the capacity 
and divide this last product by 64 for the* average. 
The quotient will give the number of red corpuscles 
per cubic millimeter. 

What is the rule for Corpuscles touching the lines? 

All corpuscles touching the right border, and base 
line, belong to that square. 

How do you count white corpuscles ? 

Proceed as before, except that a three-tenth per cent, 
solution of Acetic acid is used for diluting instead 
of the bichromate of potassium. 

Why do we use Acetic acid ? 

It dissolves out the red corpuscles and leaves the 
white alone in the field. 

What is the normal count ? 

In the adult male 5,000,000 reds, and in the female 
4,500,000 per cubic mm. The whites average about 
10,000 per cubic mm. 

What is the ratio of the red to the white corpuscles ? 

About 500 to 1, although the ratio is of less importance 
than the actual count of each. 

What is a Micro-Millimeter ? 

The one-thousandth of a millimeter, 



6o 

How is Haemaglobin estimated? 
By the Fleishl Haemometer. 

Of what parts does this instrument consist ? 

Four parts, (i) A metallic stand with a thumb-screw 
and a porcelain reflector. (2) A cylinder with a 
glass bottom, and divided into two chambers by a 
perpendicular diaphragm. (3) A framework gradu- 
ated from zero to 120 degrees and holding a wedge- 
shaped piece of red glass thicker at the darker 
end. (4) A small capillary pipette on a platinum 
handle. 

What is the procedure for estimating Haemaglobin? 

Fill both chambers of the cylinder equally with dis- 
tilled water. Touch the small capillary pipette to 
the drop of blood on the patient's thumb, and by 
capillary attraction it fills itself. Agitate in one 
chamber of the distilled water until all the blood 
has been shaken out of the pipette. Complete the 
filling of both chambers with distilled water from a 
medicine dropper. Put the cylinder in place on the 
metallic stand and in a dark room, with candle- 
light, turn the thumb-screw until the intensity of 
color reflected from the red glass through the dis- 
tilled water is identical with that of the blood mix- 
ture. Read off the number indicated and this will 
be the percentage of haemaglobin present. 



6i 

What is the Haematokrit ? 

An instrument (suggested by Blix and made by 
Hedin) which by centrifugal force collects the cor- 
puscles in the distal end of a graduated capillary 
tube. 

Describe this instrument ? 

It consists of a series of cog-wheels which transmit 
by means of a screw-thread, a rotary motion to a 
horizontal framework holding a graduated pipette 
divided into 50 parts, in which is placed equal 
volumes of blood and bichromate of potassium solu- 
tion (2% per cent.). One hundred revolutions of 
the hand-wheel produce ten thousand revolutions of 
the horizontal frame, and by centrifugal force the 
corpuscles are precipitated to the distal end of the 
pipette according to their relative specific gravity ; 
the reds being heavier occupy the extreme outer end. 
After rotating for two minutes or 100 revolutions 
of the hand-wheel, read off, with the aid of a mag- 
nifying glass, the number of volumes of red cor- 
puscles. Multiply this number by two for the dilu- 
tion, and again by two for the percentage volume 
(because only fifty volumes were employed). 

What is Dr. Daland's modification of the Haematokrit? 

(1) The mechanism is covered in. 

(2) The unsatisfactory screw-thread is replaced by .a 
cog-wheel, 



62 

(3) The capillary tube is reduced in calibre from I 
mm. to Y?, mm. and doubled in length, thus making 
it more easily read, and is divided into 200 parts. 

What is the advantage of dividing the tube into 200 parts ? 

The number of volumes read off gives the percentage 
at once, without multiplication. 

How may the number of red corpuscles be estimated from the 
number of volumes observed ? 

By adding five ciphers. 

For what purposes are these blood-counting instruments 
useful ? 
For Diagnosis, Prognosis, Treatment and Experimen- 
tation. 

What is meant by Rouleaux ? 

It is when the red corpuscles run together, looking 
like a roll of coins. 

What is Crenation? 

When blood is exposed to the air, the envelope of the 
red corpuscle shrinks up, causing the corpuscle to 
resemble somewhat a chestnut burr. This is cre- 
nation. 

In mounting blood, how is the cover-glass prepared ? 

Wash it with alcohol and pass over a flame to dry 
and warm it. 
In counting blood what microscopic power should be used ? 

About 500 diameters. 



63 

In differentiating' blood disease, what power is desirable ? 
From 800 to 900 diameters. 

In healthy blood how many white corpuscles are usually in 
any one field? 

One or perhaps none. If there should be three or 
more, suspect Leucocytosis. 

What is Leucocytosis ? 

An increase in the number of white corpuscles, but 
not so great as in Leukaemia. 

What is Plethora ? 

An increase in the total amount of blood either in 
quantity or quality. 

What microscopic change occurs in the blood in Plethora ? 

None, except an increase in the number of red cor- 
puscles, in some cases amounting to 7,000,000 per 
cubic mm. 

What is Anaemia ? 

The opposite of Plethora. A decrease in the total 
quantity or quality of the blood. 

What blood diseases directly cause Anaemia ? 

(1) Haemophilia ; (2) Progressive Pernicious Anae- 
mia ; (3) Leukaemia ; (4) Pseudo-Leukaemia ; (5) 
Chlorosis ; (6) Malaria. 

What do you mean by Hemorrhagic Leucocytosis ? 

A temporary increase in white corpuscles after a hem- 
orrhage. 



64 

"What is meant by Terminal Leucocytosis ? 

A leucocytosis occurring at the end of certain wasting 
diseases (as Cancer and Phthisis). 

What is simple Anaemia ? 

A moderate diminution in both haemaglobin and red 
count ; Whites not affected. 

What is the characteristic change in the blood in Progres- 
sive Pernicious Anaemia? 

The Red corpuscles are distorted in size and shape ; 
and the reduction in haemaglobin is not quite so 
great as the reduction in the red count, so that each 
red corpuscle has more coloring matter than normal. 

What is this distortion of red corpuscles called ? 

Poikilocytosis. 

What are the larger red corpuscles which are present in 
Pernicious Anaemia, called ? 

Megalocytes or Macrocytes. 

What name is given to those which are smaller than nor- 
mal? 

Microcytes. 

What is the characteristic blood change in Leukaemia ? 

The White corpuscles are greatly increased in number. 
Their size may also be increased by one-third. 

What is the characteristic blood change in Pseudo-Leukaemia? 

None, except a moderate degree of anaemia. 



65 

What is the blood change in Chlorosis ? 

A decided decrease in the Haemaglobin below the red 
count (Haemaglobin may fall as low as 25 per cent.) 
so that each red corpuscle has less coloring matter 
than normal. 

What is the cause of Malaria ? 

A vegetable parasite called the Plasmodium Malariae, 
which is found in the blood, in this disease. 

What are the characteristic symptoms of Malaria ? 

Chill, Intermittent fever and Sweat ; spleen enlarged 
and usually tender. 

What is the nature of the Plasmodium ? 

An amoeboid body about the size of a red corpuscle, 
partly filled with granular matter which is movable. 



MISCELLANEOUS. 



What is (Edema? 

The extravasation of the serum of the blood into 
the connective tissue spaces, causing swelling of 
the part and pitting on pressure. 

What is Hectic Fever ? 

An intermittent fever of septic origin. 

What is Thoracentesis ? 

Tapping the pleural cavity. 

Where is this best done ? 

In the seventh interspace just below the angle of the 
scapula. 

What would you do if the heart became irregular or the 
patient coughed continually during a thoracentesis ? 

Withdraw the needle. 

What kind of fremitus is produced by the whispered voice ? 

None. 

What percussion notes are associated with a sense of resist- 
ance to the finger ? 

Dulness and flatness. 

[66) 



6 7 

What is the difference between Puerile breathing and Bron- 
cho-Vesicular breathing ? 

In Broncho-Vesicular breathing the expiration is harsh 
and prolonged and associated with impaired reso- 
nance on percussion. Puerile breathing is associ- 
ated with hyper-resonance on percussion. 

What are the modifications of Bronchial breathing ? 

Cavernous and Amphoric breathing. 

What are the causes of Cavernous breathing ? 

(i) Any Excavation of the lung (from Phthisis, Abscess 
or Gangrene, Pneumothorax) ; (2) dilated bronchus. 

What are the causes of Amphoric breathing? 
(1) A large Phthisical cavity with tense walls ; and, 
(2) Pneumothorax. 

How may Amphoric breathing be imitated ? 

By blowing on the mouth of an empty bottle. 

Where can Bronchophony be heard normally ? 
Over the Thyroid cartilage (Laryngophony). 

What two Lung diseases give prolonged expiration ? 
Phthisis and Emphysema. 

How does the prolonged expiration differ in these two 
diseases ? 

In Phthisis it is harsh and associated with impaired 
resonance on percussion. 

In Emphysema it is soft and associated with hyper- 
resonance on percussion. 



68 

What is the cause of the dyspnoea in chlorosis ? 

As the haemaglobin carries oxygen, diminished haema- 
globin means diminished oxygen, hence the patient 
must breathe faster to properly aerate the blood. 

What is Jaundice? 

A brownish discoloration of the tissues and secretions 
with bile pigment. 

What causes produce Jaundice ? 

(i) Obstruction to the bile ducts (usual cause). Bile 
accumulates and is absorbed by the blood. 

(2) Disintegration of the blood (as in yellow fever 
and grave blood diseases). 

How is Jaundice distinguished from other discolorations of 
the skin? 

In other pigmentations of the skin (such as Addison's 
disease, and chlorosis) the conjunctivae and urine 
are not stained. 

What is the rough test for recognizing bilious urine ? 

A greenish tint is usually noted at the surface, and if 
the urine be agitated a thick greenish-yellow foam 
quickly form. 

What are the characteristic rales of Acute Bronchitis ? 

Dry rales — Sibilant and Sonorous. 

Where is normal Vesicular breathing best heard? 

Over the third rib in front or in the infra-axillary 
region laterally. 



6 9 

What is meant by Vomica ? 

It is another name for a phthisical cavity. 

What is the most common seat for Croupous Pneumonia ? 

The lower lobe of the right lung. 

What are the Pathognomonic signs of the first stage of 
Croupous Pneumonia ? 

Rusty sputum and Crepitant rales. 

What are the pathognomonic signs of the second stage ? 

Bronchophony and Bronchial breathing. 

What is the pathognomonic sign of the first stage of 
Pleurisy? 

The to-and-fro friction sound synchronous with res- 
piration. 

What is the diagnostic sign of the stage of effusion ? 

Movable dulness on percussion. 

What is the difference between the signs of Croupous and 
Catarrhal Pneumonia ? 

In catarrhal pneumonia signs are bilateral, less pro- 
nounced and sub-crepitant rales in place of 
crepitant. 

What are the diagnostic signs of Phthisis in the first stage ? 

Prolonged harsh expiration and Crackling rales. 

What are the valuable signs of the second stage ? 

Bronchial breathing and 'increased vocal fremitus and 
resonance with dulness on percussion. 



7o 

What are the characteristic signs of the third stage ? 

Pectoriloquy, local tympany and cavernous breathing, 
usually with bubbling rales. 
What is Anthracosis ? 

A pigmentation of the lung structure caused by coal 
dust. 
What are the valuable signs of Pulmonary Emphysema? 
Bilateral hyper-resonance on percussion, with decreased 
vocal fremitus and vocal resonance. 
What are the diagnostic signs of Pneumothorax ? 

Universal unilateral tympany, Amphoric breathing, 
and Amphoric Pectoriloquy. 
What are the Pathognomonic signs of Hydro-Pneumothorax ? 
Hippocratic succussion splash and freely movable 
dulness. 
What is the immediate cause of Fatty degeneration of the 
heart ? 
Some interference with the blood supply to the coro- 
nary artery. 
What is the most frequent form of valvular heart disease ? 

Mitral Regurgitation. (70 per cent, of all valvulitis). 
Which forms of valvular disease give a thrill ? 

Mitral obstruction (typically) and sometimes Mitral 
regurgitation, and Aortic obstruction. 
What is the Corrigan or Water-hammer Pulse ? 

A quick, full receding pulse characteristic of Aortic 
r egurgitation. 



What is the characteristic sign of the first stage of Acute 
Pericarditis ? 

The to-and-fro friction sound synchronous with the 
heart-beat, and not ceasing with respiration. 

* What is a valuable concomitant sign of Mitral Regurgi- 

tation ? 

Accentuation of the Pulmonic second sound. 

From what must Pericardial effusion be distinguished ? 

Cardiac Dilatation. 

* What form of Valvular trouble does excessive straining 

sometimes produce ? 

Aortic regurgitation. 

* What changes are produced in the size of the heart by 

mitral obstruction ? 

Enlargement of left Auricle and right Ventricle. 

* How does Mitral regurgitation affect the size of the 

heart ? 

Leads to enlargement of Left Auricle and Right and 
Left Ventricle. 

* What form of Valvulitis gives eccentric hypertrophy of 

the Left Ventricle ? 
Aortic regurgitation. 
Which forms of Valvulitis give a typically small pulse ? 

Aortic stenosis and Mitral stenosis. 

* In what Lung diseases do we get Sub-crepitant rales ? 

Capillary bronchitis ; Incipient Phthisis ; CEdema of 



the Lungs ; Catarrhal Pneumonia ; Third stage of 
Croupous Pneumonia. 

What is Dyspnoea ? 

Difficult breathing, or shortness of breath. 

What are the two kinds of Dyspnoea ? 

(i) Subjective (felt by the patient). 
(2) Objective (noted by the physician). 

What is Orthopnoea ? 

Exaggerated dyspnoea, or shortness of breath, so 
intense that the patient has to sit up to breathe. 

What is Dysphagia ? 

.Difficulty in swallowing. 

What may cause recession of the lower ribs ? 

(1) Asthma ; (2) Rickets ; (3) Laryngeal obstruction. 

What are the most frequent causes of protrusion of the 
lower ribs ? 

(1) Abdominal dropsy and (2) any enlargement of the 
liver or spleen. 

What is Subcutaneous Emphysema? 
An effusion of air under the skin. 

What is Aphonia ? 
Loss of voice. 

What is Apnoea ? 

Cessation of breathing. 



73 

What is Colic? 

A painful spasm of a mucous canal. 

What is another name for Vocal Fremitus ? 
Tactile fremitus. 

What is the difference between a rapid heart and palpita- 
tion of the heart ? 

Palpitation means a rapidly beating heart, which 
attracts the patient's own attention. (An acceler- 
ated heart-beat not recognized by the patient, is not 
Palpitation.) 

What is the duration of the First stage of Croupous Pneu - 
monia ? 

Usually about twenty-four hours. 

What is the Decubitus of the First stage ? 

Patient generally lies upon the affected side. 

In what conditions is Metallic Tinkling heard ? 

In Hydro-pneumothorax (typically) and sometimes in 
a phthisical cavity. 

What is meant by Arcus Senilis ? 

A grey area of fatty degeneration in the periphery of 
the Iris of the eye, seen in the aged. If it extends 
completely around the iris it is called the senile ring. 

What is Cyanosis ? 

A blueness of the surface from imperfect oxidation 
of the blood. Usually manifested first in the lips 
and finger-tips. 



TABLE OF DIFFERENTIAL DIAGNOSIS BE- 
TWEEN ORGANIC AND FUNCTIONAL 
HEART-MURMURS. 



ANEMIC MURMUR. 



ORGANIC MURMUR. 



1. Must be associated with I. 

anaemia. 

2. No alteration in size of \ 2. 

heart. 

3. Best heard over base of 3. 

heart. 

4. Not transmitted. 4. 

5. Varies at different 5- 

times. 

6. Soft and musical. 6. 

7. May disappear after 7. 

exercise. 

8. Not preceded by rheu- 8. 

matism. 

9. Associated % with a ven- 9. 

ous hum. 

10. Disappears under treat- 10. 

ment. 

11. Usually systolic in 11. 

time. 

(74) 



Only accidentally so. 
Usually enlarged. 
Not always. 

Generally transmitted. 
Quite constant. 

Rough and harsh. 
Intensified by exercise. 

Preceded by definite 
history. 

No venous hum. 

Not materially affected 
by treatment. 

Varies according to 
valve affected. 



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(76) 



* METHODS OF STAINING 
TUBERCLE BACILLI. 



Our ability to recognize the tubercle bacillus depends 
upon its power, after having been stained, to resist the 
decolorizing effect of acids. 

In its microscopic recognition, it is more satisfactory 
to use a y 1 ^ oil immersion lens. 

I. Weigert-Ehrlich Method : 

Spread a thin film of the thickest part of the spu- 
tum on a cover-glass and dry by holding it several 
inches above an alcohol flame. When cool, place 
in the staining fluid prepared as follows : Mix 5 
c.c. of aniline oil with 100 c.c. of distilled water; 
filter and add 11 c.c. of a saturated solution of 
fuchsin in alcohol. Leave cover-glass in stain for 
half an hour (in doubtful cases for twenty-four 
hours), wash in distilled water : then decolorize in 
thirty per cent, aqueous solution of nitric acid for a 
few seconds. Wash off acid with distilled water 
and counter-stain for one minute in an aqueous 
solution of methylene blue, or in a two per cent, 
aqueous solution of Bismarck Brown ; rinse, then dry 
and mount in Canada Balsam. 

(77) 



78 

II. Ziehl's Method : 

i. Spread thin film of morning sputum on cover-glass. 

2. Dry in the air. 

3. Stain for three to five minutes with Carbol-Fuch- 

sin. 

f Fuchsin 2. 

Carbol-Fuchsin -< ^ u v A * . -, , a * 

j Carbolic Acid (five per cent. 

t aqueous solution) 100. 

Drop the stain upon the cover until it is full. 
Hold over a lamp until white fumes begin to rise. 
Continue to keep hot three to five minutes. 

4. Wash in water. 

5. Decolorize and counter-stain (blue) for exactly 

thirty seconds with .Gabbett's solution : 
f Methyl blue 2. 
< Sulphuric acid 25. 
(Water 75. 

6. Wash in water until only a faint blue color remains. 

7. Dry thoroughly in the air. 

8. Mount with a drop of Canada Balsam. 






* URINE. 



What are the characteristics of Normal Urine ? 

Light amber-colored liquid, acid reaction and specific 
gravity from 1015 to 1025. 

To what does the urine owe its color ? 

To the presence of urobilin, a constituent of bile. 

How does the intensity of color vary ? 

It increases with the specific gravity (except in dia- 
betic urine, which has a high specific gravity and is 
very pale.) m 

Upon what does the Acid reaction depend ? 

Upon the presence of acid sodium phosphate (and not 
free acid). 

What is the origin of the Acid sodium phosphate ? 

It results from the sodium phosphate of the blood 
coming in contact with the uric acid of the urine. 

Upon what does the specific Gravity of Urine depend ? 
Upon the amount of solids in solution. 

What are the chief solids concerned ? 

Urea (organic) and Sodium Chloride (inorganic). 

What is the average quantity of urine voided ? 
About fifty ounces in twenty four hours. 

(79) 



8o 

How can the percentage of solid matter be approximate y 
estimated from the specific Gravity ? 

Multiply the last two figures of the specific gravity 
by 0.233. 

(Thus if specific gravity = 1020 ; multiply 20 by 
0.233 = 4.66 per cent, solids.) 

Why does normal urine become alkaline after standing for 
some time ? 

The urea is decomposed into Ammonium Carbonate 
by the micrococci present. 

How can you detect the presence of Sodium Chloride in the 
Urine ? 
Add a few drops of Nitric acid, and treat with nitrate 
of silver. If sodium chloride is present in normal 
quantity, a white curdy precipitate will form. If it 
is diminished in quantity only a milkiness will occur. 

What may interfere with this test ? 

The presence of Albumen, which must be removed by 
coagulating and filtering. 
How do you test the reaction of Urine ? 

With Litmus paper. Acid turns blue to red, alkaline 
turns red to blue. Neutral has no action on either 
color. 
What is the ordinary way of testing for Albumen ? 

Heat the urine to the boiling-point and add one- 
tenth its volume of Nitric Acid. If any albumen 
be present it will be precipitated. 



8i 

What is the appearance of Albuminous urine ? 
Pale in color and has a low specific gravity. 

What is the test for sugar in the Urine ? 

Boil some Fehling's solution with four times its 
volume of water. Add two or three drops of urine 
at a time and heat after each addition, if sugar is 
present a yellowish-red precipitate will be formed. 

What is the general appearance of Diabetic urea ? 

Paler than normal ; sweet taste, no odor, and high 
specific gravity (1030 to 1060.) 

What is a good test for Bile in the Urine ? 

Allow a specimen of urine and a few drops of red 
fuming nitric acid to gradually intermingle on a 
porcelain dish, and an iridescent " play of colors " 
will occur if bile be present. 

How can you determine the percentage of Urea ? 

Mix one volume of urine with seven volumes of 
Labarraque's solution, which causes a reduction in 
specific gravity by decomposing the urea. After 
half an hour, multiply the loss in specific gravity by 
0.77, which gives the percentage of Urea present. 



THE NEW EPITOME. 

944 

Examination Questions on Anatomy. 

—BY— 

M. LEVIS and W. HENRY PRICE, M.D. 



A valuable collection of the most important questions on Anatomy ; with their con- 
cise answers. 

Gathered from the final examinations on Anatomy in the principal medical colleges. 

Favorite questions with all examiners. 

Approved by leading Anatomists. 

Endorsed by the many students who have successfully and creditably passed their 
examination by its aid. 

It will save many times its price, in time and worry, and will give you that confi- 
dence in yourself so necessary upon the day of examination. 

" These gentlemen have prepared this little work with great care and thoroughness. 
It will be very useful to students in -showing them what questions are asked in examina- 
tion, and the importance of answering in as few words as possible * * * Every 
student of anatomy can find information in its pages, and we cannot do better than to 
heartily recommend it '' — Internatio7ial Medical Magazine, April, 1892. 

* * * >' The various structures of the boriy are concisely considered, ard under 
the head of Miscellaneous many surgical questions are given. A table on the Association 
of Anatomical Facts by Numbers is most excellent. The book closes with a table of 
hernia coverings and one of the centres of ossification. The typography is very good. 
We take great pleasure in recommending this book and think it would prove a valuable 
aid to all that wish to obtain quickly a theoretical knowledge of such an extensive subject 
as anatomy." — University Medical Magazine, January, 1893. 

" As long as the present system of State examinations and medical education exists, 
there will be a use for books, the object of which is to aid the student in condensing the 
considerable and varied medical knowledge he has received from his instructors. What 
is wanted by both teacher and student at an examination is, that the latter should be 
able to answer the questions asked him in a manner showing the greatest amount of 
knowledge in the fewest possible words. In anatomy this process of classification and 
condensation is particularly hard, and the average student is grateful for any means that 
will aid him in this direction. The little book, entitled g+f Examination Questions on 
Anatomy, by Drs. M. Levis and W. Henry Price, seems to fill a want among the 
laboring students of anatomy; it has been compiled with care by the authors, from 
actual questions asked at the examinations of medical colleges and State Boards through- 
out the United States. During the past year it has been thoroughly revised, so as to be 
up to the most recent examinations. The printing and binding of this little book are 
excellent, and we think it will be well received by students generally." 
WM. H. WELLS M.D , 

Late Assistant Demonstrator of Anatomy, 
* Jefferson Medical College, Philadelphia. 



Bound in Cloth. Price, $1.00 Net. 

FOR SALE BY 

JOHN JOS. McYEY, 39 North 13th Street, Philadelphia, 



Three Charts of the Nervo-Yascular System. 

Part I.— The Nerves. Part II.— Tlie Arteries. Part III.— The Veins. 

A New Edition, Revised and Perfected. Arranged by W. Henry Price, 
M.D., and S. Potts Eagleton, M.D. Endorsed by leading anatomists. 
Clearly printed upon extra durable paper. 

Part I. The Nerves. — Gives in a clear form not only the Cranial and 
Spinal Nerves, showing the formation of the different. Plexuses and their 
branches, but also the complete distribution of the Sympathetic Neryis. 
Part II. The Arteries. — Gives a unique grouping of the Arterial system 
showing the divisions and subdivisions of all the vessels, beginning from 
the heart and tracing their continuous distribution to the periphejy, 2nd 
showing at a glance the terminal branches of each artery. 
Part III. The Veins. — Shows how the blood from the periphery of the 
body is gradually collected by the larger veins, and thes^, coalescing, 
forming still larger vessels, until they finally trace themselves into the 
Right Auricle of the heart. 

These charts have been publicly recommended and endorsed before 
large classes of medical students by several of the leading anatomists of 
Philadelphia, including Prof. Piersol, Professor of Anatomy in the Univers- 
ity of Pennsylvania; Dr. A. Hewson, Jr., Demonstrator of Anatomy in the 
Jefferson Medical College ; Dr. John B. Deaver, Associate Professor of 
Anatomy; Dr. Edmund W. Holmes, Demonstrator of Anatomy, and Dr. 
H. C. Deaver, Assistant Demonstrator of Anatomy in the University of 
Pennsylvania. 

Price, postpaid, in United States and Canada, 50 cts. net, complete; 
in Great Britain, 3s. 6d. ; in France, 3 fr. 60. 

" These charts are well gotten up, and cannot fail to be of great service to medical 
students." — Joseph Leidy, M.D., LL.D. 

" For the student of anatomy there can possibly be no more concise way of acquiring 
a knowledge of the nerves, veins and arteries of the human system. It presents at a 
glance their trunks and branches in the great divisions of the body. It will save a world 
of tedious reading, and will impress itself on the mind as no ordinary vade mecum ever 
could. Its price is nominal and its value inestimable. No student should be without it." 
— Pacific Record of Medicine and Surgery. 

«< * # # Xhe three sheets, comprising the set cf charts beiore us, present admirable 
tabular condensations of the nerves, arteries and veins, so arranged that a glance suffices 
to recall the branches of any vessel or nerve. The giouping together of all the nerves — 
cranial, spinal and sympathetic — on a single page is a feature, we believe, peculiar to 
these charts, and one of great convenience. * * *"— -Prof. Piersol, in International 
Med. Mag., March, 1892. 

" These ate three admirably arranged charts for the use of students, to assist in 
memorizing their anatomical studies." — Buffalo Med. and Stir g. Journal. 

For sale at F. A. DAVIS'S, 1914 Cherry St., and 
MORRIS'S BOOK STORE, 3307 Woodland Ave. 



LIBRARY OF CONGRESS 

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